PLANNING A PREGNANCY WHEN YOU HAVE DIABETES

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1 PLANNING A PREGNANCY WHEN YOU HAVE DIABETES If you have diabetes and are planning a pregnancy, it is important that you talk to your Diabetes Specialist Nurse (DSN) or Hospital Doctor beforehand. Contact the DSN at Trafford General Hospital to arrange this ( ). This is because the level of blood glucose control at the time of conception is very important. Forward planning is needed to ensure tight control in preparation for conception. Don t wait until you are pregnant before turning attention towards tightening up on blood glucose control. Good blood glucose control will help reduce the risks of health problems to yourself and your baby. To achieve this, you may need some help to adjust your diet or diabetes treatment or advice on performing extra blood tests. If your diabetes is treated with insulin, you may need to change your insulin dose or even change the number of injections you take, in order to improve your overall control. If your diabetes is treated with tablets, it is advisable that the tablets are replaced with insulin injections before you start a pregnancy. If you are on diet alone for your diabetes, then you may need to be started on insulin at some stage before or during pregnancy. BEFORE BECOMING PREGNANT, there are a number of things for you to consider: Make sure that your blood glucose is as near to normal as possible for at least 3 months before you try to become pregnant. This means 4-6 mmols before meals and no higher than 8 mmols 2 hours after a meal. Your long-term control is usually assessed by the HbA1c test. Ideally you should be aiming to have this below 7.0 % before becoming pregnant. It is important to take regular Folic Acid supplements for at least 3 months before, and for the first 3 months of, any pregnancy. Lack of folic acid could put your baby at a higher risk of developing Spina Bifida. For a mother with diabetes we usually advise 5 mg tablets (rather than the usual 0.4mg tablets advised for mothers without diabetes). These tablets will need to be prescribed by your GP as the dose you need is much higher than what is available 'over the counter' in a pharmacy. Have your Rubella (German Measles) status checked by a blood test. If you are not immune to this, you will need to be vaccinated. If you smoke, please stop - ask if you need help. (See the leaflet Smoking) 1

2 If you are on tablets for blood pressure control, these may need to be changed to medication known to be safe in pregnancy If you are on tablets to lower cholesterol, these are often stopped in preparation for the pregnancy and for the duration of the pregnancy It is important that you continue with your usual contraception until you and your Diabetes Team are happy that it is safe for you to become pregnant and give you the 'go-ahead'. Once there is a gap of 5 weeks since the start of your last period, have a pregnancy test done. As soon as you have confirmation that you are pregnant, tell your DSN, ( ) who will arrange for you to have an early visit to the hospital Ante-natal Clinic and pregnancy diabetes clinic. DURING PREGNANCY Now that you are pregnant, the hard work really starts! It is important that you keep your blood glucose as near to normal as possible for the whole of your pregnancy. High blood glucose before and in early pregnancy could prevent your baby from developing normally. High blood glucose during a pregnancy causes the baby to grow quickly and become overweight, especially in the last 3 months. This can lead to problems for you during delivery (greater chance of Caesarean section or forceps delivery). It could also mean that your baby is more likely to be born prematurely or have problems controlling his/her blood glucose immediately after birth (neonatal hypoglycaemia). Blood Tests and Insulin Doses You will be asked to test your blood glucose at least 4 times daily (before each meal and before bedtime) but extra tests may be necessary. For good control the blood glucose should be kept between 4-6 mmols before meals. To achieve this level of good control, you may need extra insulin injections and your overall daily insulin dose will increase. Often you will end up taking around 2-3 times your usual daily dose - this is normal. As soon as the baby is born, your insulin dose will return to your pre-pregnancy level. Hypos In early pregnancy it is not uncommon to experience hypos more frequently. You may also find that the warning symptoms of hypoglycaemia are different from usual. It is important to be careful about driving, sleeping through snacks or spending long periods of time alone. If you are having frequent hypos, then it may be wise to stop driving altogether until you are around 16 weeks (or more) pregnant; your Diabetes team can advise you if you are worried about this. Hypos may be more severe in pregnancy and you may need help from a friend or relative to treat them if you are unable to swallow sugary drinks. Friends or family can be taught to treat hypos using Glucogen injections, which can be prescribed by your GP. (See the leaflet Hypoglycaemia What is it?) 2

3 Clinics You will be asked to attend the hospital frequently for assessment by both the Diabetes team and the Obstetric team. They are based at Trafford General Hospital. Initially you will be seen every 4 weeks but later in pregnancy you will be seen every week. At around 19 weeks you will have a detailed ultrasound scan to check your baby's size and development. From around 26 weeks, the baby will begin to put on weight; it is important to keep you glucose control as near normal as possible at this time to avoid the baby growing too large. From about 28 weeks you will have a scan every 2 weeks to check on your baby's growth. When you reach 36 weeks, ask your DSN and midwife about how your labour will be managed and start to write your labour and delivery plan with your birth partner. You could teach your birth partner how to do blood testing. They also should know how to recognise your 'hypo' symptoms. LABOUR AND DELIVERY The aim is to try for a normal labour and vaginal delivery where possible. Sometimes, if the baby has become overweight or your blood pressure is rising, the obstetrician may wish to induce labour early. Ask your obstetrician or midwife about how this will be done in your case. During labour your insulin injections and calories (nutritional requirements) will be given in a 'drip' containing glucose and insulin. The amount of insulin will be adjusted every hour depending on your blood tests. The drip will continue until after the baby is born. After Delivery You will go back to taking the dose of insulin you were on before your pregnancy began. Insulin requirement will have slowly risen during the pregnancy, but falls rapidly immediately after the baby is born. Babies born to mothers who are treated with insulin sometimes go to the Special Care Baby Unit (SCBU) for a short time for observation. You will be given the opportunity to visit the SCBU during your pregnancy and ask the staff there any questions you might have. Breastfeeding Women with diabetes can breastfeed! You must remember to increase the amount of starchy foods you eat at each meal. This is because breast milk is high in carbohydrate. You may also require less insulin while breastfeeding as the baby is taking carbohydrate away from you. Test before and after a few feeds so that you know how much to adjust your insulin and food intake by. Going Home You no longer need to be as strict about your glucose control as you were during pregnancy. It is important to avoid hypoglycaemia. Remember you will be dealing with a new baby and sleepless nights! Your DSN will keep in contact with you and will arrange a date for you to be assessed by the Diabetes and Obstetric staff. You will usually have a postnatal check when the baby is 6 weeks old. Any outstanding issues in relation to your diabetes will be discussed and your medication may be changed, for instance if you had to change your blood pressure tablets when you were pregnant. 3

4 One of the most important issues at your postnatal check is contraception. Remember that breastfeeding is not a reliable form of contraception You must contact the DSN ( ) if you have any concerns in relation to your diabetes when you have gone home. Type 2 Diabetes and Pregnancy: You are most likely to have been taken through pregnancy on insulin. The blood glucose targets are exactly the same for both Type1 & Type2 patients. Following delivery, you will return to your pre-pregnancy medication wherever possible. Exceptions sometimes occur: e.g. if one of the tablets for glucose control is incompatible with breast feeding. We are now seeing far more people with Type2 diabetes going through pregnancy than was the case 20 years ago. The need for on-going dietary vigilance, portion control, calorie control and regular exercise must be stressed in the post-natal care for patients with Type2 diabetes. FREUENTLY ASKED UESTIONS ABOUT PREGNANCY What if I have an unplanned pregnancy? A Do not panic! These things can happen, and although it is better to plan if possible, there are also things we can do to help if you come to see the DSN and Doctor in early pregnancy. Let us know as soon as possible after your positive pregnancy test and we will give you advice and help on an individual basis. Will my baby get diabetes? A There is a small lifetime increase in the risk that your baby will develop diabetes, but not enough that anyone should be put off having a family for this reason. If a baby s mother has Type 1 diabetes the baby has a chance of around 2: 100 of developing diabetes by the age of 20. Interestingly, there is a slightly greater risk if the baby s father has diabetes (around 6: 100) and greater still if both parents have diabetes. Can I have a normal labour? A Many women will be able to have a normal labour and delivery. We would never recommend that a woman with diabetes could have a home birth, and when you are in labour you will need an insulin and glucose drip to keep your blood glucose stable. This can be done in the normal delivery rooms at the hospital and your partner/family member can be with you if you wish. Will I need a caesarean section? A It is by no means inevitable, but statistically you are more likely to need a caesarean birth. This is mainly due to the fact that babies born to diabetic mothers tend 4

5 to be big and are sometimes difficult to deliver normally. Please discuss this at the antenatal clinic. Will my baby need to go to the special care baby unit? A Again, it is not inevitable. Some babies of diabetic mothers have low blood glucose (sugar) after birth, so the baby s blood will need to be checked regularly. Usually they just need extra feeding, but sometimes a baby with low blood glucose will require a glucose drip in which case they will need to stay on the special care baby unit until the blood glucose level remains stable. If this happens, you should still be able to breast feed and bond with your baby. Author: - Diabetes Multidisciplinary Team. Version no 1.Issue Date: - June 2004.Review Date: - June 2006 Author: - Diabetes Multidisciplinary Team. Version no 2.Issue Date: - Jan Review Date: - Jan